Chapter 5: The Golden Hour

INTRODUCTION

First described in the field of emergency medicine, the “golden hour” refers to the first 60 minutes following an injury. It was discovered that the sooner trauma patients received definitive care, the better their outcomes. In neonatology, the term “golden hour” refers to the initial 60 minutes of an infant’s life following delivery when a critical transition period of adaptation takes place. Particularly for high-risk neonates, optimizing thermoregulation, glycemic control, cardiorespiratory support, and nutrition during this time is critical to achieving successful long-term outcomes. The golden hour provides opportunity for an evidence-based standardized approach to achieve these goals. Evidence shows that implementation of a golden hour protocol decreases mortality as well was the incidence of hypothermia, chronic lung disease, intraventricular hemorrhage, and retinopathy of prematurity.

I. GOLDEN HOUR FOR THE TERM INFANT

1. The golden hour protocol for a term newborn is composed of delayed cord clamping, maintaining thermoregulation, and the initiation of early breast feeding.

2. Counseling/team briefing

   1. If there is risk a term newborn will require interventions immediately after birth, the parents should be counseled and the management plan explained prior to delivery.

   2. As with all neonatal resuscitations, clear roles and responsibilities should be established among the team members and all resuscitation equipment prepared.

   3. For an anticipated admission to the neonatal intensive care unit (NICU), staff should be notified.

3. Delayed cord clamping (DCC)

   1. Per American College of Obstetricians and Gynecologists (ACOG) and Neonatal Resuscitation Program (NRP), clamping of the umbilical cord should be done after at least 30 to 60 seconds. World Health Organization (WHO) guidelines are 1 to 3 minutes after birth.

   2. Delayed clamping for 1 minute leads to a transfer of approximately 80 mL of extra blood to the term neonate.

   3. NRP recommends using DCC for all term infants who do not require resuscitation after birth.

   4. Benefits include higher hemoglobin at 2 to 12 months of age and an increase in total body iron during the first year of life.

   5. DCC may increase the risk for jaundice and need for phototherapy.

   6. Umbilical cord milking is an alternative to DCC but currently not recommended by the NRP.

4. Preventing hypothermia

   1. Normal temperature in a newborn is between 36.5°C and 37.5°C.

   2. Neonatal hypothermia has been shown to increase neonatal mortality.

   3. The highest risk of neonatal hypothermia is immediately after birth due to the difference in in utero and environmental temperature.

   4. Interventions to prevent hypothermia include raising the temperature of the delivery room, using a radiant warmer, and early initiation of skin-to-skin contact.

      1. The newborn should be received in warm blankets and skin-to-skin contact should be started immediately if no resuscitation is required.

      2. The delivery room temperature should be kept between 23°C and 26°C (74°F and 77°F).

5. Respiratory support

   1. Oxygen support and pulse oximeter

      1. When resuscitation is needed, a pulse oximeter should be placed on the right upper hand or wrist.

      2. Resuscitation of a term newborn should start in room air (21% oxygen) and be titrated ...